Mary­land has the only all-payer hos­pi­tal-rate reg­u­la­tion sys­tem in the coun­try un­der a decades-old Medi­care waiver. Since 1977, the state’s Health Ser­vices Cost Re­view Com­mis­sion has set the prices hos­pi­tals charge pa­tients, re­gard­less of their in­surance cov­er­age.

The state has also been an out­lier for an­other rea­son: its read­mis­sion rates. His­tor­i­cally, they were high com­pared to the rest of the coun­try. In 2010, when 18.6% of Medi­care pa­tients in the U.S. were hos­pi­tal­ized again within 30 days of dis­charge, Mary­land’s rate was 2.7 per­cent­age points higher. In 2014, the Mary­land com­mis­sion and the CMS In­no­va­tion Cen­ter re­quired Mary­land hos­pi­tals to close that gap by 2018.

At the Univer­sity of Mary­land St. Joseph Med­i­cal Cen­ter, a 232-bed hos­pi­tal in Tow­son, a quar­ter of high­risk pa­tients were hos­pi­tal­ized again within 30 days. So the hos­pi­tal be­gan de­ploy­ing com­mu­nity health work­ers tasked with help­ing these pa­tients ad­dress press­ing non­clin­i­cal is­sues af­ter they leave the hos­pi­tal.

“You can­not un­der­es­ti­mate the im­por­tance of ad­dress­ing the psy­choso­cial needs of pa­tients upon dis­charge,” said Dr. Gail Cun­ning­ham, St. Joseph’s chief med­i­cal of­fi­cer. “The best med­i­cal plan in the world is go­ing to fail if some of the pa­tient’s ba­sic needs aren’t met.”

In its first 16 months, read­mis­sion rates for pa­tients en­rolled in the pro­gram dropped by 60%. In May, about 10% of St Joseph’s high-risk pa­tients were read­mit­ted within 30 days, com­pared with 25% when the hos­pi­tal launched the pro­gram in Fe­bru­ary 2015 in part­ner­ship with med­i­cal staffing com­pany Maxim Health­care.

To identify pa­tients who are highly likely to be read­mit­ted, a nurse prac­ti­tioner in­ter­views pa­tients be­fore dis­charge and ver­i­fies their risk level. Then, the nurse prac­ti­tioner sets up a care plan with a reg­is­tered nurse out­side the hos­pi­tal as well as a com­mu­nity health worker to fig­ure out how to ad­dress the pa­tient’s needs.

Within two days of dis­charge, the reg­is­tered nurse goes to the home to en­sure that the pa­tient doesn’t have other un­met needs. They per­form clin­i­cal as­sess­ments too.

But it is the com­mu­nity health worker who is es­pe­cially crit­i­cal. Pa­tients ex­pe­ri­ence a wide range of chal­lenges af­ter they leave the hos­pi­tal. Some need help get­ting pre­scrip­tions or fill­ing out job ap­pli­ca­tions. Many lack fam­ily sup­port at home and are prone to fall­ing. Some suf­fer from de­men­tia or ad­dic­tion. Or they live in food deserts with lim­ited ac­cess to nu­tri­tious food. In one case, a pa­tient sim­ply needed help get- ting a mat­tress. The com­mu­nity health work­ers can help meet those needs them­selves or con­nect pa­tients with other re­sources.

Over the course of 30 days, the com­mu­nity health worker vis­its a pa­tient at home five to 10 times. The reg­u­lar­ity of the vis­its means that the worker builds trust and a re­la­tion­ship with the pa­tient.

The nurse prac­ti­tion­ers, reg­is­tered nurses and com­mu­nity health work­ers are all em­ployed by Maxim. It was Maxim that ap­proached St. Joseph, Cun­ning­ham said, to ex­plore the idea of ex­am­in­ing non­med­i­cal fac­tors that con­trib­ute to read­mis­sions and us­ing com­mu­nity health work­ers to re­duce un­nec­es­sary re­turns.

Since the pro­gram’s launch, nurse prac­ti­tion­ers have car­ried out some 1,600 as­sess­ments of high-risk pa­tients; roughly 1,200 have opted into the pro­gram—about 5% of the pa­tients the hos­pi­tal dis­charges each year. From Fe­bru­ary 2015 to July 2016, St. Joseph used a to­tal of 15 com­mu­nity health work­ers to look af­ter about 1,200 pa­tients. Six to 10 com­mu­nity health work­ers were em­ployed at any given time.

Ini­tially, Maxim fo­cused on hir­ing cer­ti­fied nurs­ing as­sis­tants as com­mu­nity health work­ers. But the com­pany has be­gun to broaden the qual­i­fi­ca­tions to in­clude emer­gency med­i­cal tech­ni­cians, home health aides and oth­ers with rel­e­vant back­grounds.

Maxim trains these work­ers in el­e­ments of both clin­i­cal and com­mu­nity health work, said Andy Friedell, a vice pres­i­dent at Maxim. For in­stance, they learn mo­ti­va­tional in­ter­view­ing, a tech­nique for be­hav­ior change that in­volves en­gage­ment and em­pa­thy. They put in roughly 10,000 hours of work be­tween Fe­bru­ary 2015 and May 2016, Friedell said.

St. Joseph plans to ex­pand com­mu­nity health worker ser­vices to the be­hav­ioral health pop­u­la­tion, and Cun­ning­ham said she hoped the pro­gram ul­ti­mately will ben­e­fit all high-risk pa­tients as more pay­ers see the ben­e­fits for their bud­gets, and for pa­tients.